=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144310426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TROMBLY MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15040 HARPER AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-2962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-839-8728
-----------------------------------------------------
Fax | 313-839-4099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15040 HARPER AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-2962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-839-8728
-----------------------------------------------------
Fax | 313-839-4099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HOME MANAGER
-----------------------------------------------------
Name | WALDINE BATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-839-8728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | AM82000989
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------